20 January 2010

I've assiduously avoided writing about the politics of health care reform for the past couple of months, for a number of reasons. First of all, it has been such a fluid situation that my the time I could put any sensible commentary together it was already out of date. Also, with excellent analysts like Ezra and Jon Cohn and others on the job, I didn't feel that I had a lot of substance to offer beyond linking to them. And finally, since the whole thing was being played out on the big stage in DC, so very far away, it's not like like my voice was going to have any impact on the debate. So I've watched carefully and I've kept mum. Mostly.

I'll make a few observations on the status of things now, in the wake of the MA debacle, then resume radio silence till there's any substantive developments to comment on once more.Is it time to write Health Reform's post mortem?Sure seemed like it this morning. Congressional Democrats, in one of their most disgusting displays of political cowardice, started a full-on freak-out, with liberal stalwarts joining jittery centrists in declaring the whole game over. The Senate leadership preemptively declared defeat. Conservadems in the senate like Bayh and Nelson who never wanted reform in the first place also took the opportunity to head for the door and declare the whole thing done. Then Obama implied that the reform bill should be dropped and maybe something smaller could be passed instead. This is the sort of galling weakness that makes it insanely frustrating to be a democrat. These people are contemptible. Talk about a worst-case scenario.

Whose fault is this mess anyway?Boy there's plenty of blame to go around. The old saying is that success has a thousand fathers but failure is an orphan; not in this case. It's Martha Chokely's, fault, for blowing a gimme special election. It's Ted Kennedy's, for dying at such an inopportune time (sad joke, not funny). It's the MA Democratic party's fault, for screwing with election laws over and over. It's Harry Reid's and Max Baucus', for wasting months of time in a fruitless quest for GOP cooperation. It's Lieberman's and Nelson's, for being preening egotists and holding the bill hostage. It's Obama's, for not using the bully pulpit to continue to make the moral case for universal coverage. It's FOX's, for cynically and repeatedly lying about the proposed bill and demagoguing the issue relentlessly. It's the feckless Democrats' fault in general, for failing to keep their caucus together and legislate effectively. It's the GOP's, for their nihilistic approach of obstruction and refusal to compromise.

The list could go on for pages. I guess it doesn't matter. We are where we are, and if it works out in the end, all sins will be forgiven -- but not necessarily forgotten.What comes next?Best I can tell, the Senate has decided not to do anything till Brown is seated. (Funny how the Senate didn't wait for Al Franken or Roland Burris, though, innit?) Which means that the original strategy of the ping-pong of the Senate bill back to the House and then back to the Senate is dead. There's some suggestion of getting Snowe (or even Brown? He does have to run again in MA in 2012) back on board with some policy compromise, but I suspect that is a fool's hope.

Apparently, the plan is that the Senate bill, which has been passed, will be approved verbatim by the House, then signed into law by the President. House liberals will not agree to this, however, unless the Senate bill is improved, and improved it can be, through the reconciliation process, which as we all now know takes only 51 votes. The good news is that the major items of contention for "fixing" are appropriate for the reconciliation process, because in some way they affect the deficit -- the excise tax, the expansion of Medicaid, the Nelson Nebraska buy-off, etc. The bad news is that this process could take a while, which could be fatal. The opponents of reform smell blood, and the popularity of reform will probably continue to plummet in the face of increased attacks.Will it work?I think it will. Not because I'm deranged, or an incurable optimist. But because the electoral calculus for the dems is very clear: pass this thing or it's 1994 again. If this fails, the narrative will be that the Dems tried to do this awful thing and isn't it great that the people gave the GOP back enough power to stop them. That's a formula for electoral disaster. Pass it, and you can take a victory lap, talk about all the goodies in the bill, and gain some time to let the backlash die down before facing the voters. Winning matters in politics. I think in the end, simple self-preservation will compel the democrats to finish what they started. But really, at this point, who the hell knows?

Why is this effort still worth supporting?This is the case that the supporters of reform need to start making (again) and more forcefully. To this point, we've been so embroiled in policy fights (public option) and internecine warfare (Baucus, Nelson) that Dems have inflicted their worst injuries on themselves. They've not played offense at all. Now there's little possibility of changing the bill -- the cement is poured -- so Dems can and must put aside the squabbling and remind Americans that despite the ugliness of the process, what we have is a relatively centrist, good bill. We can stop apologizing for it and promote it: It's a guarantee that nobody will ever need to worry about losing their health care coverage ever again. It's a promise that exploding health care costs will (start to) be contained. It's an end to some of the worst abuses of the insurance industry. It's the closing of the Medicare Part D donut hole. It gives individual consumers more choice, and fairer choices. It's more funding for primary care and prevention. It extends the solvency of the Medicare program by nine years. It's fully paid for and reduces the deficit. It's a good start, a historic start, that future congresses can build on and improve.

It's time to take a deep breath, get back on the proverbial horse, and get out there and make our case to the American people that this health reform bill is still, after all, what America needs now. And then let the chips fall where they may.

If you're in favor of affordable health care for all, please tell me how your physician group is reducing costs/bills for the uninsured. Certainly that's the moral thing to do, right?

Most certainly, you are not saying universal healthcare is moral when you are losing money (otherwise you'd either be immoral or only charging what the patient deemed 'affordable'), so, please, leave "morality" out of it. You want the American public and struggling businesses to be taxed at a higher rate to pad your own pocketbook. Yawn.

One minor point: I don't think it's so much that Congress is waiting for Brown to be seated. It's that once the special election was held the guy in what will be Brown's seat couldn't vote anymore anyhow so the Democrats don't have the 60 votes they need to stop a filibuster.

I took a look at a timeline for the Senate bill's provisions and I'm not seeing a lot that's going to reassure voters before the 2010 elections. The Democrats may be able to run on what the bill is going to do in later years but I suspect the impact in 2010 is going to be largely higher costs.

One exception is that pre-existing conditions can't be excluded from coverage in the individual market. That should be reassuring to those who fear getting sick, losing their jobs, losing their health insurance, and not being able to buy a new policy now that they're sick. However, if the bill still lets insurers charge more for those with pre-existing conditions, those policies are going to be awfully expensive. If it doesn't, then everyone's insurance premiums are going to go up to cover the additional costs.

The other 2010 provisions are going to push premiums up and it seems to me that the 21% cut to physician reimbursement that goes into effect on March 1 is going to make doctors, the elderly, and the relatives of the elderly unhappy.

And, finally, I'm not all that happy with Republicans right now but I feel compelled to point out that Democrats have been able to do whatever they want since July 1, 2009. That's six months and 18 days to pass health care regardless of how obstructionist, dishonest, and nihilistic (have you read Dennis the Peasant on this?) the GOP is.

"We can stop apologizing for it and promote it: It's a guarantee that nobody will ever need to worry about losing their health care coverage ever again. It's a promise that exploding health care costs will (start to) be contained. It's an end to some of the worst abuses of the insurance industry. It's the closing of the Medicare Part D donut hole. It gives individual consumers more choice, and fairer choices. It's more funding for primary care and prevention. It extends the solvency of the Medicare program by nine years. It's fully paid for and reduces the deficit."

Just give my patients access to real insurance coverage. I know many recently unemployed, who have attempted to purchase insurance and have been denied coverage. Others who have had to provide labs in order to get approval, but yet still have any possible preexisting condition denied. Fact is most will not qualify once the underwriting process is complete.

I am always surprised when some health professionals can't see the other side of things. Heck, you get fired from your job, let's see you afford COBRA. And think you can go tap a few healthcare favors from your old facility? It ain't the 70s anymore... nobody's going to "take care" of you.

Would you ever have thought you'd be glad for EMTALA? Here's to you sitting in chairs some day.

I am one of the uninsured. I have been for six years now. The last employer I had couldn't afford health insurance for the employees even with contributions.

I am now unemployed and have been for eighteen months. Yes, I am looking diligently and getting nowhere. I can't get private insurance due to pre-existing conditions.

I would dearly love health insurance I could afford. I am not asking for free coverage. I would just like something that would enable me to see a doctor for my ills, a physical, and prescription renewals. I can't afford it. I had a health scare recently that cost me $2500 for two doctor visits, one lab test and a diagnosis of needing surgery with four days in the hospital for recovery.

While I had credit cards to float the $2500, I can't afford the cost for surgery. I don't qualify for Medicaid. Hence I get to live in pain until I manage to find a job which may or may not provide health insurance as a benefit.

So, yeah, I really wish this country had affordable health coverage. Congress has been debating this issue for what, forty years? I have seen the proposal that Nixon made for a government health plan. After reading the current proposals his looks pretty damn reasonable not to mention acceptable.

Americans like to talk about economy and the "market". There are, however, areas of society and places/circumstances that BETTER NOT run like a market: Healthcare, Education, Justice, Public Services and War.

With all of America's might and potential, the Americans people will eventually need to decide what they want for what they give: a [cut-throat & short-sighted] market place or a society.

Moreover, Americans enjoy giving each other derogatory nicknames and playing sides as if it's a game or entertainment or sort. Ask yourself this: are you so sure that you want important legislatures to get loss in such name-calling shuffle?

If in doubt, ask your children, won't you.

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Some think that democrats haven't worked hard enough to promote the reform bill through US Congress. Where do you those precious "60 votes" (needed to prevent a filibuster) came from? bubblegum exchange?

A large majority of Americans are outright ungrateful. After suffering nearly 8 years of mismanagement under the previous administration, now the chance comes to turn things around under the leadership of a darn smart n' passionate president. Yet, many folks still prefer the status quo; they play politics.

(BTW, is it true that Americans enjoy more being entertained than being informed? Surely you are better than that!)

Very well, i will look for the USA under "second-rated society" in a few years (already there on many indexes). It's your choice. Remember Japan - learn from their mistakes, not repeating them.

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"Is that all there is?"

Ask YOURSELF this: IS IT? Reform [of any sort] only stops when you stop.

If you want to point fingers, point them at those who actually [directly or indirectly] oppose the registration for no better reason than "i simply don't like the sound of that." Keep shooting at the good guys (by calling them morons or 'lack of spine' or sort) and all you will end up getting is a basket full of [dedicated and all-too-powerful] bad apples.

Pointing finger at those who [directly or indirectly] toil over the reform is the political equivalent of shooting ourselves in the foot. This is democracy, not dictatorship - i.e. horizontal rather than vertical power structure - you/they need to muster enough support (via negotiation and at times compromises) to get a bill passed. I'm sure a lot of us won't like it if some dude just run people over and get the bill passed.

I'm wondering if Shadowfax would be in favor of universal health care if he made the average French physician's salary of $55,000. Certainly they are more MORAL that the US, right? With that MORALITY comes middle-class wages for physicians eventually.

I'm sure Shadowfax would go running a mile away from Morality if his wages were cut from $325,000 or so per year to $55,000.

Perhaps by "morality" you meant "income" or "reasonable compensation." The two are a world apart, just in case you can't figure it out. Not happy with your own pay grade? Grip to your nurse administrator already; stop projecting your own bitterness if you don't have anything better to say.

If you think universal healthcare is about wealth redistribution, you are likely as ignorant as those "death panel" idiots.

Shadowfax has said previously that he stands to gain quite a bit of money personally from this bill passing. It's odd that "morality" in his mind also is correlated with a large increase in his personal income and a reduction in nearly everyone else's + longer wait times to see a doctor (meaning my insurance premium is instantly more costly because the value is decreased).

Of course, the average joe might get insurance and will be shocked when the health care infrastructure doesn't support him as a consumer. It's like giving insurance to all the Haitians...BFD...you need the infrastructure to support all these new people before it isn't just another tax and another bolus of people using the ER as a clinic (and Shadowfax getting paid $350 or whatever for URIs and strep throats instead of doing it for free for the exact same clientele).

Totally bored by people that think giving everyone insurance is going to do anything other than clog up the ER and increase wait times for primary care like it did in Massachusetts. Not like this hasn't been tested and failed on a statewide level.

The key is beefing up primary care and public health infrastructure. You do realize that the reform is far more than just providing coverage for the uninsured,* right? Tell me why would a nation spend far more per capita on healthcare yet end up being so limited on providing reasonable care.

One of your clogs is most likely the insurance POLICY rather than 'waves of the uninsured' that you fear would overburden the system. Stop making the uninsured the convenient scapegoat.

* Public coverage was deleted from the reform bill very early on, btw.

This is where the bitter battle rages: between the health care system itself and the industries that entangle and strangle it.

'UnitedHealthcare says the proposed rule is meant to improve the quality of care and cut costs by allowing insurance case managers to jump in right away.'

Where the fuck are the big-ticket healthcare bloggers like yourself NOT to challenge such insurance companies' nonsense? If you don't; who will? Politicians? They are a bit out of range, don't you think? Picking on politicians who toil over current political deadlock, doctors over their paychecks or the uninsured over their their lack of coverage. That's very low.

Great post. I have wonderful health insurance from my employer right now. But five years ago I was unemployed and turned down by 4 insurors due to a pre-existing condition. I got pneumonia and now owe $30,000 to the doctors and the hospital, which I will be paying on for many years.

It IS immoral that the richest country in the world allows its citizens to suffer in pain and sometimes die due to their lack of insurance (45,000/year die per the NEJM). Many have had to file bankruptcy due to overwhelming medical expenses.

IF we have to choose between a system with massive human suffering and 45,000 needless deaths of year, or have doctors make $55k/year, I'll go with the latter. HOWEVER, that's a false choice. We can spend less on the military, regulate pharmaceutical prices, and decrease total medical spending via a public option.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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